- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $4,677.35
| Facility | | $1,819.70 | $1,819.70 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,949.84 / $2,398.83
| Professional | | $1,819.70 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,897.79 / $5,888.44
| Professional | | $3,388.44 | $4,897.79 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,715.35
| Professional | | $2,951.21 | $2,951.21 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $4,677.35
| Facility | | $1,548.82 | $1,949.84 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,090.30 / $5,128.61
| Professional | | $1,071.52 | $3,090.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,630.27 / $4,365.16
| Professional | | $1,071.52 | $2,630.27 | $4,365.16 |